Knowledge and behaviors of nurses working at Inonu University Turgut Ozal Medical Center on childhood vaccine refusal

ABSTRACT

Among 10 global problems of 2019 determined by the World Health Organization, vaccine refusal was one of the problems mentioned. In this context, health services and health personnel whose main objectives are to keep individuals healthy and to prevent diseases have major responsibilities. This study aims to analyze knowledge and behavior of nurses working at Inonu University Turgut Ozal Medical Center on childhood vaccine refusal.

This study, conducted between June and July 2019, is a descriptive cross-sectional study. It was conducted in a hospital located in Malatya in eastern Turkey. At the time of the study, 850 nurses work in this hospital. Sample size was calculated to be 263 at a confidence interval of 95% and strength of 80%. Chi-square test and Fisher’s exact test were used in statistical analyses.

In the present study, 31.7% of the participating nurses stated that they had concerns about childhood vaccines. Two-thirds of nurses stated that their knowledge on vaccines was from their education. The level of hesitance in those agreeing to the fact that vaccines caused autism and infertility, those stating that they did not trust vaccine-producing companies, and those stating that catching the disease was a better immunization method than vaccination was significantly higher than those not agreeing to these and those who were indecisive (p < .05).

One-third of nurses was proven to have hesitance on childhood vaccines, and this rate is rather high. Nurses, being both health personnel and the communication channel for guiding parents, should be provided necessary training and practices in order to ease their hesitance on vaccination.

KEYWORDS:

• Child health
• knowledge
• nurses
• vaccine
• vaccination refusal

Introduction

The World Health Organization (WHO) defines immunization as a process in which an individual is immunized or made resistant to an infectious disease by being administered a vaccine. It has been determined that vaccination, which is considered to be one of the biggest gains of preventive healthcare services, prevents 2–3 million deaths annually and significantly reduces mortality and morbidity due to infectious diseases.^1,2

The main purpose of vaccination is to protect the individual and the society, and it is possible to protect the health of the society with the level of social immunity obtained with successful vaccination programs. Although vaccine-preventable diseases are rare in many countries, the agents causing these diseases can infect anyone who is not immune to these diseases by crossing geographical borders and causing pandemics.³ According to a report published by WHO, the mortality rate of measles decreased by 73% globally with vaccination.⁴

In order to protect against epidemics of vaccine-preventable diseases, at least 95% of the population should be vaccinated. However, the vaccination rate achieved with three doses of diphtheria, tetanus, pertussis (DTP3), and one dose of measles vaccine is approximately 86% worldwide since 2010.⁵

According to the Strategic Advisory Group of Experts (SAGE) report by WHO in 2012, it is said, “Vaccine hesitancy refers to the delay in accepting vaccines or the refusal of some vaccines despite the provision of vaccination services.” When vaccine hesitancy was examined, it was observed that this behavior may vary depending on time, place, and type of vaccine to be administered.¹ As a result of the increase in this behavior, vaccine refusal was included among the 10 global problems that WHO identified for 2019. In this context, health services and healthcare personnel, whose main purpose is to protect the health of individuals and prevent diseases, have great responsibilities in preventing vaccination concerns.⁶

The escalation of the vaccine refusal phenomenon in our country is thought to be clearly related to the reflection of an issue that occurred in 2015 to the media. The Provincial Directorate of Family and Social Policies filed a complaint on the grounds of a health precaution. Against the parents of a set of twin babies who did not vaccinate their twins in Ordu. Afterward, however, the parents filed a counter-lawsuit and won. This attracted the attention of the society.⁷ Again, according to the data of the Ministry of Health in our country, vaccine refusal has increased in recent years, and on examining the data, the number of families rejecting vaccines exceeded 10,000 in 2017 and reached 23,000 in 2018.⁸

Healthcare workers have an important place in the decision-making process of parents about vaccination as they are the group of people from whom families receive information about vaccines most frequently.⁹ Hence, the level of anxiety in nurses, who are among the healthcare workers found to have an effect on the decisions and behavior of the society regarding vaccines, should be studied. Further, the knowledge and behavior of nurses about childhood vaccination refusal should be examined.

The aim of this study is to determine the knowledge and behavior of nurses working at Inonu University Turgut Ozal Medical Center, about childhood vaccine refusal.

Materials and methods

This descriptive cross-sectional study was conducted between June and July 2019. We obtained written permission from the chief physician office of the Inonu University Turgut Ozal Medical Center and ethics committee approval from the Inonu University Scientific Research and Publication Ethics Committee (2019/248). For this study, we considered 850 nurses working at a hospital in Malatya eastern of Turkey. In calculating the sample size, at 95% confidence interval and with 80% power, when the rate was taken as 56% for the answer given to the question of the reference study “I do not trust the vaccine producing companies,” it was calculated as 263. We included 265 nurses working at a hospital and who agreed to participate in the study.

A questionnaire form consisting of 21 questions that was created by the researchers based on literature review was distributed to be filled out by the nurses. An observational survey technique was used while collecting the data of the study. The first part of the questionnaire included questions on the sociodemographic characteristics of the nurses and their children, and the second part included questions determining the knowledge and behavior of nurses about childhood vaccine refusal. Age, monthly income, and age of children questions are open-ended, other questions of the questionnaire are closed-ended. Triple Likert-type questions were used to determine their knowledge and behavior about childhood vaccines. The independent variables of the study were sociodemographic characteristics of the nurses and their children as well as the answers given to the questions about their knowledge and behaviors about childhood vaccinations, whereas the dependent variable was the anxiety of nurses about childhood vaccinations.

The analysis of the available data were carried out using the SPSS 22.0 program. The descriptive data were presented as numbers, percentages, median, minimum and maximum while the Chi-Square test and the Fisher’s exact test were used for statistical analyses. In all statistical analyses, the significance level was accepted as p < .05.

Results

The distribution of sociodemographic characteristics of the nurses participating in the study is presented in Table 1. The median age of the nurses is 32 (22–53). Among the included subjects, 30.6% of the nurses were male, and 69.4% were female.

Table 1. Distribution of sociodemographic characteristics of the nurses participating in the study

Sociodemographic characteristic	n	%
Age group
20–29	101	38.1
30–39	115	43.4
≥40	49	18.5
Gender
Male	81	30.6
Female	184	69.4
Branch of work
Pediatrics	38	14.3
Non-Pediatric internal	132	49.8
Surgery	95	35.8
Education status
High school graduate	16	6
University/college graduate	249	94
Average monthly income of the family
≤4500 Turkish Lira (TL)	44	22.6
4501–6500 TL	49	30.3
6501–8500 TL	54	27.7
≥8501 TL	38	19.5
Marital status
Married	159	60
Single	102	38.5
Other	4	1.5
Children
Yes	134	50.6
No	131	49.4

When the sources of information about childhood vaccination obtained by the nurses participating in the study were examined, it was determined that 69.8% of the nurses obtained it from school education, 37% from the internet, 36.2% from family physicians, 29.4% from books, 21.5% from family/friends, 20.4% from scientific articles, and 14.3% from television programs.

As shown in Tables 2, 21.5% of them stated that the chemicals in vaccines caused autism and similar diseases. Further, 21.2% stated that they did not trust the companies producing vaccines, 19.8% of them stated that better immunity was obtained by having the disease instead of vaccination, and 1.9% stated that vaccines were not beneficial.

Table 2. Distribution of the answers given to the questions for knowledge and behavior of nurses participating in the study of childhood vaccines

	n	%
Knowledge and behavior There are studies reporting side effects of vaccines.	122	46.2
Chemical substances in vaccines cause autism and similar diseases.	57	21.5
I do not trust companies that produce vaccines.	56	21.2
Better immunity is acquired by having a disease instead of vaccination.	52	19.8
Complementary and alternative medicine is more effective and has less side effects.	51	19.3
Vaccines damage children’s immune system.	21	7.9
There are no studies proving the reliability of vaccines.	20	7.5
Vaccines have no use.	5	1.9

While 31.7% of the nurses participating in the study stated that they were worried about childhood vaccinations, 82.4% stated that they would like to wait or see others get it first when a new vaccine is available.

The comparison of hesitancy status of the nurses in the study group of childhood vaccinations according to sociodemographic and various other variables is demonstrated in Table 3. Among the nurses participating in the study, hesitancy status of the 20–29 age group was found to be significantly higher than that of the other groups (p = .01). No significant difference was observed between the hesitancy status of the nurses according to their education and monthly income (p > .05). Among the nurses participating in the study, it was observed that the hesitancy status of single nurses was significantly higher than that of the other groups (p = .013). Among the nurses participating in the study, 39.7% of those who did not have children and 23.9% of those who had children were worried about childhood vaccines with those who did not have children had a significantly higher hesitancy status (p = .006). The hesitancy status of the nurses who wanted to wait or see others have it when a new vaccine is available (34.4%) was significantly higher than that of those who said it was not necessary (17.4%) (p = .024)

Table 3. Comparison of the hesitancy status of nurses in the study group of childhood vaccinations according to sociodemographic and various other variables

	Vaccine hesitant		Vaccine acceptance
Sociodemographic and Various Other Variables	n	%	n	%	p
Sex					0.341
Male	29	35.8	52	64.2
Female	55	29.9	129	70.1
Age Group
20–29 ^a	39	38.6	62	61.4	0.01
30–39	38	33.0	77	67.0
≥40	7	14.3	42	85.7
Education					0.251
High school graduate	3	18.8	13	81.3
University/college graduate	81	32.5	168	67.5
Monthly Income
≤4500 Turkish Lira (TL)	14	31.8	30	68.2	0.374 0.013
4501–6500 TL	22	37.3	37	62.7
6501–8500 TL	12	22.2	42	77.8
≥8500 TL Marital status Married Single ^b Other	11 40 43 1	28.9 25.2 42.2 25.0	47 119 59 3	71.1 74.8 57.8 75.0
Children					0.006
No	52	39.7	79	60.3
Yes	32	23.9	102	76.1
Wanting to wait and see someone else get it when a new vaccine becomes available					0.024
Yes	74	34.4	141	65.6
No	8	17.4	38	82.6

a; Differs from 30–39 y old and ≥40 y old.

b; Married and differs from Other.

As shown in Table 4, the hesitancy status of the nurses who disagreed that the chemical substances in the vaccines cause autism was significantly lower than those who agreed or were undecided (p = .01). Hesitancy status of the nurses who agreed with the idea “I do not trust the vaccine producing companies” (57.1%) was significantly higher than the ones who disagreed (22.9%) and those who were undecided (25.9%) (p = .001). While 55.8% of the nurses who agreed that better immunity is acquired by having a disease instead of vaccination was anxious, 20.4% of those who did not agree to this and 39% of those who were undecided were also anxious. A statistically significant difference was observed among the groups (p = .001). Furthermore, we observed that 85.7% of the nurses who agreed that the children’s immune system is not fully developed and that vaccines damage the immune system, 22% of those who did not agree to this, and 45.3% of those who were undecided were anxious, and there was a statistically significant difference among the groups (p = .001). The hesitancy status of the nurses who agreed that there are no studies proving the reliability of vaccines (65%) was significantly higher than the hesitancy status of those who did not agree (29%) and those who were undecided (28.9%) (p = .004).

Table 4. Comparison of nurses’ knowledge and behaviors about childhood vaccinations and their hesitancy status

	Vaccine hesitant		Vaccine acceptance
	n	%		n	%	p
Chemicals in vaccines cause autism.
Agree	27	47.4		30	52.6	0.01
Disagree ^a	22	19.8		89	80.2
Undecided	35	36.1		62	63.9
I do not trust companies that produce vaccines.
Agree ^a	32	57.1		24	42.9	0.001
Disagree	22	22.9		74	77.1
Undecided	29	25.9		83	74.1
Better immunity is acquired by having a disease instead of vaccination.
Agree ^b	29	55.8		23	44.1	0.001
Disagree ^c	31	20.4		121	79.6
Undecided ^d	23	39.0		36	61.0
Children’s immune systems are not yet fully developed and vaccinations damage the immune system.
Agree ^b	18	85.7		3	14.3	0.001
Disagree ^c	42	22.0		149	78.0
Undecided ^d	24	45.3		29	54.7
There are no studies proving the reliability of vaccines.
Agree	13	65.0		7	35.0	0.004
Disagree	47	29.0		115	71.0
Undecided	24	28.9		59	71.1
Vaccines are not useful.
Agree	4	80.0		one	20.0	0.001
Disagree	61	26.2		172	73.8
Undecided	19	70.4		8	29.6

a; differs from the others.

b, c, d; differ from each others.

Discussion

In the present study, 69.8% of the nurses in the study group stated that their source of information on childhood vaccinations was school education, while 37% relied on the internet, and 36.2% family physicians. In a cross-sectional study conducted in our country, it was observed that the source of information used by parents about vaccines was health centers (81.5%), and in two different studies conducted in the USA, the major source of information used by parents about vaccines was found to be doctors and other health professionals.^9–11 In a study conducted in Norway, it was found that public health nurses’ sources of information about vaccines are mostly publications by the National Public Health Institute.¹² In a study conducted in Turkey, it was shown that the sources of information used by parents who refuse childhood vaccines about vaccines are healthcare professionals (39.3%) and social media (39.3%) equally.¹³ In the studies conducted previously and in our study, it was observed that the most important source of information on vaccines for nurses is school education and that for parents is mostly healthcare workers. Hence, it can be said that school education of healthcare professionals about vaccines is crucial. Further, the importance of the advantages of vaccination should be included in the education curriculum during university education along with courses with up-to-date scientific information about how to prevent increasing vaccine refusal in the society.

In the present study, 31.7% of the participating nurses stated that they were worried about childhood vaccinations. In a study conducted on healthcare professionals in Barcelona, 25.6% of the participants stated that they had doubts about at least one of their vaccines in the current vaccination schedule.¹⁴ In a study conducted in the USA, 25% of the parents were worried about vaccines, whereas in a population-based study in Croatia, it was found that 19.5% of the participants were worried about vaccines and 10.6% refused vaccines.^15,16 Consistent with our study, other studies have also reported that the vaccine concern rates of both healthcare professionals and parents are high and, therefore, in-service training can be conducted intermittently to eliminate this concern, as the attitudes of both nurses and healthcare professionals who provide vaccination services may affect the society.

No significant difference was found between the hesitancy status of the nurses participating in the study group and their education status and monthly income. In terms of marital status, the hesitancy status among singles was determined to be higher than in married nurses and the “other” category. In a study conducted in Brazil, vaccine acceptance rates were found to be significantly lower in singles, those with low monthly income, and those with low education.¹⁷ The hesitancy status of the nurses in the study group who do not have children is significantly higher. Similar to our study, in a study conducted in Croatia, vaccine hesitancy was found to be higher in those who did not have children than those who had a child.¹⁶

In the study group, when the participants’ hesitancy status regarding childhood vaccinations was compared according to their age groups, the hesitancy status of the 20–29 age group was significantly higher than that of the other groups. Similarly, in a study conducted in Brazil, it was determined that individuals younger than 25 of age were the least likely to accept vaccination.¹⁷ It can be said that education, awareness, and experience increase in direct proportion to age.

Participating in the study, the hesitancy status of the nurses who agreed with the thought that chemical substances in vaccines cause autism and infertility, and those who believed that vaccines harm the immune system of children were significantly higher than those of the other groups. In a case-control study conducted in Turkey, it was determined that 12.1% of the parents who rejected at least one vaccine for their children thought that vaccines cause autism, 15.2% thought that vaccines cause infertility, and 51.5% thought that vaccines could be dangerous for children.¹⁵ In a study conducted in India, it was shown that one of the reasons for vaccine hesitancy and vaccine refusal was the thought that vaccines cause infertility.¹⁸ Further, in a population-based study conducted in the USA, it was observed that 30% of the parents thought that vaccines cause autism.¹⁹ As shown in our study and in studies conducted in other countries, it can be said that the opinion that vaccines cause autism and infertility in the society as well as among healthcare professionals who direct the society, and false information on vaccines increases concerns. In this context, discussions on the results of scientific studies on vaccines should be included in the academic curriculum for healthcare workers to eliminate this concern.

In our study, we observed higher hesitancy status in those who want to wait and see while others take a newly available vaccine. In a study conducted on healthcare professionals in Barcelona, it was stated that participants who were concerned about childhood vaccinations had lower confidence in the newly released vaccines.¹⁴ In addition, those who think that there are not enough studies proving the reliability of vaccines in our study group have a significantly higher hesitancy status. In order to reduce existing concerns and prejudice in individuals against newly released vaccines, data and scientific publications proving reliability and effectiveness of these vaccines must be clearly presented by both vaccine companies and the Ministry of Health to reduce the concern of existing bias against newly released vaccines.

Participating in the study, the hesitancy status of nurses who agreed with the thought that they do not trust companies producing vaccines was significantly higher than the other groups. In a study conducted on healthcare professionals in Europe, one-third of the participants stated that they did not trust vaccine manufacturers.²⁰ Similarly, one-fifth of the nurses in our study group stated that they did not trust companies that produce vaccines. In addition, 7.9% of the nurses stated that vaccines damaged the immune system of children, and 1.9% stated that vaccines are not useful. In a case-control study conducted in the USA, half of the participants stated that vaccines damaged the immune system, whereas one-tenth stated that vaccines might not work.⁹ In a study conducted in Brazil, lack of confidence (41.4%) and disbelief in the effectiveness of the vaccine (25.5%) were shown as the most common reasons for vaccine hesitancy.¹⁷ In order to eliminate the lack of confidence and hesitation in individuals, they can be provided with easy access to accurate and transparent information to understand the situation in all aspects.

In the present study, 21.5% of the participating nurses stated that chemical substances in vaccines caused some diseases, and 7.5% stated that there were no studies proving the reliability of vaccines. Similarly, in a population-based study conducted in the USA, 26% of the participants stated that the content of vaccines was unsafe, and 17% stated that the reliability of vaccines was not adequately tested.¹⁹ Further, in a national vaccine research study conducted in the United States, it was shown that 93% of parents rated vaccines as safe, 6% as neither safe nor unsafe, and 1% as unsafe.²¹ In our study, the anxiety level of those who thought that there were no studies proving reliability of vaccines was found to be significantly higher than the other groups. In this case, it can be thought that accurate and effective information about vaccines should be provided in order to reduce the level of anxiety.

Approximately one-fifth of the nurses participating in the study stated that better immunity was acquired by having a disease instead of by vaccination. In addition, the hesitancy status of these people was found to be significantly higher in our study group. In a study conducted on mothers with newborn babies in Canada, 13.9% of those who were worried about childhood vaccines agreed with the idea that better immunity was acquired by having a disease instead of by vaccination, whereas 38.2% were undecided.²² It should be ensured that every segment of the society adopts the idea that immunity can also be acquired through vaccination, and vaccination is important because it provides primary prevention in terms of preventing complications that may occur as a result of the disease.

Among the healthcare professionals who are accepted in the society, the nurses in the study group have a high hesitancy status about childhood vaccines. It can be said that a lack of confidence in vaccine manufacturers as well as the prevalence of false information and misconceptions contributes to their concerns. These include beliefs such as vaccines cause autism and infertility and damage the immune system of children and that having the disease is preferable to getting vaccinated to acquire immunity. By disseminating accurate and effective information among nurses, vaccination concerns can be eliminated both in nurses and in the society indirectly as nurses’ attitudes may affect those of the society.

The limitation of the present study is that it was conducted in one hospital only.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Acknowledgments

We would like to thank all of the nurses whom participated in this research.

Additional information

Funding

The authors declared that this study has received no financial support.